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A nurse is caring for a client who has acute angina. Which of the following actions should the nurse take first?
- A. Measure blood pressure.
- B. Administer aspirin.
- C. Administer nitroglycerin.
- D. Initiate IV access.
Correct Answer: B
Rationale: The correct answer is B: Administer aspirin. Aspirin helps to reduce platelet aggregation and prevent further clot formation in clients with acute angina, thus reducing the risk of myocardial infarction. Administering aspirin should be the first action as it addresses the immediate risk of clot formation and helps improve blood flow to the heart muscle.
Measuring blood pressure (A) can be important but is not the priority in this situation. Administering nitroglycerin (C) is important for symptom relief but does not address the underlying cause. Initiating IV access (D) may be necessary later for further interventions, but it is not the first priority.
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A nurse is caring for a client who has a new onset of hyperglycemic hyperosmolar state (HHS). Which of the following interventions by the nurse is the highest priority?
- A. Administer Insulin.
- B. Teach the client about manifestations of HHS.
- C. Measure the client's urinary output.
- D. Initiate IV fluid replacement.
Correct Answer: D
Rationale: The correct answer is D: Initiate IV fluid replacement. In hyperglycemic hyperosmolar state (HHS), the client is severely dehydrated due to high blood glucose levels. IV fluid replacement is the highest priority to rehydrate the client and improve circulation. Administering insulin (A) is important but not the highest priority as fluid replacement takes precedence. Teaching the client about manifestations of HHS (B) is important for long-term management but not the immediate priority. Measuring urinary output (C) is important to assess renal function but not as critical as rehydrating the client.
A nurse is caring for a client who is 3 hours postoperative following a total knee arthroplasty. Which of the following actions should the nurse take to prevent venous thromboembolism?
- A. Encourage the client to perform circumduction of the foot.
- B. Keep the client's knees in a flexed position while they lie in bed.
- C. Massage the client's legs every 4 hours while they are awake.
- D. Limit the client's fluid intake to 2,000 mL daily.
Correct Answer: A
Rationale: Correct Answer: A. Encourage the client to perform circumduction of the foot.
Rationale:
1. Circumduction of the foot promotes blood flow in the lower extremity, preventing stasis and reducing the risk of venous thromboembolism.
2. This action helps in maintaining muscle tone and preventing blood clots in the postoperative period.
3. Encouraging mobility also prevents complications like deep vein thrombosis.
Summary of Incorrect Choices:
B. Keeping the client's knees in a flexed position may restrict blood flow and increase the risk of thromboembolism.
C. Massaging the client's legs can dislodge blood clots and lead to embolism.
D. Limiting fluid intake can increase the risk of dehydration and thickening of blood, which can contribute to thrombus formation.
A nurse is providing discharge teaching to a client who has a new prescription for sublingual nitroglycerin. Which of the following statements made by the client indicates an understanding of the teaching?
- A. I can take another dose after 2 minutes.'
- B. I can put the tablet against my cheek and gum.'
- C. I should chew the tablet before I swallow it.'
- D. I should take this medication as soon as the pain begins.'
Correct Answer: A
Rationale: The correct answer is A: "I can take another dose after 2 minutes." This statement indicates an understanding of the teaching because sublingual nitroglycerin is typically used for acute chest pain relief due to angina, and the client should take another dose if the pain persists after 5 minutes, up to a total of 3 doses at 5-minute intervals. This is crucial for managing angina attacks effectively.
Choice B is incorrect because the tablet should be placed under the tongue, not against the cheek and gum. Choice C is incorrect because the tablet should not be chewed but allowed to dissolve under the tongue. Choice D is incorrect because nitroglycerin should be taken at the onset of chest pain, not after the pain begins, for optimal efficacy.
A nurse is providing discharge teaching to a client who reports that they cannot afford their prescribed medication. Which of the following statements should the nurse make?
- A. I can arrange for a social worker to talk with you before you leave.'
- B. I can contact the occupational therapist to schedule a home visit.'
- C. Contact your pharmacy to inquire about a different medication.'
- D. You should ask your provider to prescribe a cheaper medication.'
Correct Answer: A
Rationale: The correct answer is A: "I can arrange for a social worker to talk with you before you leave." This option is the most appropriate as it addresses the client's financial constraints by offering assistance in accessing support services. A social worker can help the client explore options for medication assistance programs, financial aid, or community resources. Option B is incorrect as it does not directly address the client's medication affordability issue. Option C suggests switching medications without considering the client's specific needs. Option D places the burden on the client to navigate the healthcare system for cost-effective solutions. Option A is the best choice as it prioritizes addressing the client's financial barriers through appropriate referral and support.
A nurse is caring for a client who has just returned from surgery with an external fixator to the left tibia. Which of the following assessment findings requires immediate intervention by the nurse?
- A. The client's capillary refill in the left toe is 6 seconds.
- B. The client has 100 mL blood in the closed-suction drain.
- C. The client has an oral temperature of 36.3° C (90.9° F).
- D. The client reports a pain level of 7 on a scale from 0 to 10 at the operative site.
Correct Answer: A
Rationale: The correct answer is A. Capillary refill time of 6 seconds in the toe indicates poor circulation, which is a concerning finding post-surgery with an external fixator. Immediate intervention is needed to prevent complications like tissue ischemia. Choices B, C, and D do not require immediate intervention as they are within normal limits postoperatively. Blood in the drain is expected, the temperature is normal, and pain level 7 is manageable with appropriate pain management.